Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management

Introduction

Dyspepsia describes a range of symptoms arising from the upper gastrointestinal (GI) tract, but it has no universally accepted definition. The British Society of Gastroenterology (BSG) defines dyspepsia as a group of symptoms that alert doctors to consider disease of the upper GI tract, and states that dyspepsia itself is not a diagnosis. These symptoms, which typically are present for 4 weeks or more, include upper abdominal pain or discomfort, heartburn, gastric reflux, nausea or vomiting. In this guideline, gastro-oesophageal reflux disease (GORD) refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease.

Some of the costs associated with treating dyspepsia are decreasing, but the overall use of treatments is increasing. As a result, the management of dyspepsia continues to have potentially significant costs to the NHS.

The use of endoscopy has increased considerably over the past decade, as awareness of its value in investigating dyspepsia and GORD has grown.

The review of the previous NICE guideline on dyspepsia: management of dyspepsia in adults in primary care highlighted some concerns about the drug regimens that were recommended in the guideline for Helicobacter pylori (hereafter referred to as H pylori) eradication, because some bacterial resistance has developed. Overall, the review process concluded that some guidance in this area should be updated and expanded to cover aspects of specialist hospital care.

The previous NICE guideline on dyspepsia covered the management of several underlying causes of dyspepsia in primary care, but there is a lack of comprehensive national guidance about managing GORD (in particular, surgical management) when pharmacological treatments fail. Because of this, and the possible role of GORD (with the subsequent development of Barrett's oesophagus) as a risk factor for cancer, the scope of the guideline update was extended to cover managing GORD in secondary care.

This guideline update covers adults (18 years and older) with symptoms of dyspepsia, symptoms suggestive of GORD, or both. It also covers endoscopic surveillance for adults with a diagnosis of Barrett's oesophagus, but it does not cover the management of Barrett's oesophagus. It is important to note that children and young people (younger than 18 years) and people with a diagnosis of oesophagogastric cancer are not covered in this guideline update.

In this guideline, specialist care is defined as treatment decisions made by a consultant-led service in secondary or tertiary care.